Satellite Manual

3.3 Extravasation Management

The following procedures outline recommendations for the prevention and treatment of extravasation of chemotherapy agents. Chemotherapy should only be administered by an Association of Pediatric Hematology/Oncology Nurses (APHON) certified personnel with demonstrated knowledge of and clinical skills in the administration of chemotherapy. Maintain provider status as per APHON standards. Extravasation can occur with either peripheral intravenous (PIV) or central line intravenous administrations.

Definitions

Extravasation is the inadvertent leakage of vesicant drug or solution into the tissues surrounding an intravenous (IV) site.Vesicant is an agent that can cause blistering or tissue necrosis when extravasated.Irritant is an agent that can cause a local inflammatory reaction but does not cause tissue necrosis when extravasated.None refers to an agent that is considered not to be a vesicant or an irritant.Signs of extravasation include the following:

Pain and/or burning in the infiltrated area

Swelling near the IV injection site or along venous tract

Erythema in the infiltrated area

Poor or absent blood return from the IV catheter

Increase in IV pump pressures

Signs of irritant or vesicant extravasation:

Aching and tightness along vein

Full length of vein may become erythematous and/or discolored

Swelling unlikely

Usually able to get blood return

Flare Reaction

No pain

Immediate blotches or streaks along vein which usually subside within 30 minutes with or without treatment

Below is a list of antineoplastic vesicants and irritant drugs classified into the following categories:(See Section ‘Guidelines for Management of Extravasation of Vesicant Antineoplastic Drugs’ below)

Ensure good blood return from site prior to administration, during and upon completion. If infusion is less than one hour check for blood return every 15 min. If greater than one hour check site and blood return every hour.

Frequent monitoring if PIV/port needle sites or CVC site and monitor for increase in pump pressures.

Extravasation supplies should be available.

Starting a New PIV for Administration of Vesicant Drugs

Choose PIV site carefully. Choose the most distal position of a vein and in this order if possible:

Dorsum of hand

Forearm

Wrist (potential damage to tendons and nerves should extravasation occur)

Avoid the antecubital fossa since this area is dense with tendons and nerves; damage here can result in loss of structure and function.

If first attempt is unsuccessful, select another site preferably in another limb. Avoid a distal point in the same vein because of the potential for extravasation “downstream”.

Guidelines for Management of Extravasation of Vesicant

The following guidelines are recommended for the management of extravasation. The medical team should be notified immediately and treatment must be individualized to each extravasation event.

*It is unclear whether injection of antidotes into area of extravasation is of benefit. Most small extravasations do not result in serious problems without the injection of antidotes.” (BCCA Cancer Drug Manual, BC Cancer Agency November 2014.)

Detach IV tubing/syringe from the IV/port needle. Attach a new syringe to the IV/port needle as close as possible to insertion site. Aspirate as much drug, blood and tissue fluid as possible. Remove the syringe.

Extravasation known: Return to clinic in 24-48 hours for assessment, then weekly for one month minimum.Extravasation suspected: Telephone call in 24 hours by nurse to assess and then in one week minimum.

Provide Information to patient/ family with what to look for and when to call. The site should be observed daily by the patient and/or parent for one month as there may be delayed reaction.

Guidelines for Management of Extravasation of Irritant DrugsThe following guidelines are recommended for the management of extravasation. The medical team should be notified immediately and treatment must be individualized to each patient. While the medical team may elect to use an antidote if one exists, or topical medications, it is important to realize that many patients recover fully with no drug treatment at all.

Detach IV tubing/syringe from IV/port needle. Attach a new syringe to IV/port needle as close as possible to insertion site. Aspirate as much drug, blood, and tissue fluid as possible. Remove the syringe.

For PIVs, restart the IV at another site, preferably in the opposite limb or in the same limb proximal to the infiltrated area, if needed. For Ports, re-access to heparin lock or re-establish IV.

8.

Immobilize the affected limb or area. Elevate the affected area to promote venous drainage and to reduce edema.

9.

Document the extravasation of occurrence in the patient’s chart and complete your hospital safety report. Photo documentation may be helpful. Consent may be required.

10.

Consult Plastics upon MD or Nurse Practitioners discretion and/or no improvement of site in 24 hours.

11.

Extravasation known: Return to clinic in 24-48 hours for assessment, then weekly for one month minimum.Extravasation suspected: Telephone call in 24 hours by nurse to assess and then in one week minimum.

Provide Information to patient/ family with what to look for and when to call. The site should be observed daily by the patient and/or parent for one month as there may be delayed reaction. Click here for sample documents.

3. Allow DMSO to air dry. Do not cover and repeat QID for at least 7 days.

4. Elevate limb and apply gentle pressure to site.

5. Apply ice pack wrapped in towel or cold compresses to the extravasation site for 1 hr; continue cold compresses x 15-20 min, qid for 24-48 hrs. Care must be taken to avoid tissue injury from excessive cold.

DMSO speeds up removal of the drug from the tissue and is a free-radical scavenger.

Air-drying is required as DMSO may cause blisters with occlusions.

Cold compresses cause vasoconstriction and decrease fluid absorption.

VinBLAStine

VinCRIStine

Vindesine

Vinorelbine

WARM

1. Remove IV/port needle

2. MD to administer antidote*: hyaluronidase 1500 units dissolved in 1 mL of either sterile water for injection or normal saline injection infiltrated into affected area subcutaneous in a clockwise fashion in divided doses around the site ( as soon as possible after extravasation).14

3. Elevate limb and apply pressure to site

4. Apply warm compresses to extravasation site for 1 hr; continue warm compresses 15-20 min qid for 24-48 hrs. Care must be taken to avoid injury from excessive heat.

3. Apply ice pack wrapped in towel or cold compresses to the extravasation site for 1 hr; continue cold compresses for 15-20 min, QID for 24-48 hours. Care must be taken to avoid tissue injury from excessive cold

Busulfan

Carmustine

DOCEtaxel

Melphalan

PACLitaxel

Streptozocin

COLD

1. Remove IV/port needle.

2. Elevate limb and apply gentle pressure to site.

3. Apply ice pack wrapped in towel or cold compresses to the extravasation site. Continue cold compresses for 15 to 20 minutes QID for 24 to 48 hours. Care must be taken to avoid tissue injury from excessive cold.

Supply of AntidotesA supply of antidotes should be readily available and maintained in areas where chemotherapy is administered for easy access.

Hyaluronidase (See Antidote table above)* 1500 units’ injection is a Special Access Medication. A future use supply should be kept in the Pharmacy so that doses may be administered as soon as they are ordered. A Special Access request form must be submitted within 24 Hours.

NOTE: For drugs and antidotes not listed please consult Pharmacy. For non-vesicant/irritant antineoplastic drugs please refer to your hospital guidelines on the treatment for extravasation.

The superiority of dexrazoxane over DMSO has not been established.Dexrazoxane is not included in this policy and DMSO remains the standard of care for anthracycline extravasation. References are provided for a situation where dexrazoxane use may be deemed warranted.